Dott. MAURIZIO CAPPUCCINO

SPECIALISTA IN GHIRURGIA GENERALE – UNIVERSITA’ STATALE DI MILANO SPECIALISTA IN CHIRURGIA PEDIATRICA – UNIVERSITA’ STATALE DI MILANO SPECIALISTA IN CHIRURGIA VASCOLARE – UNIVERSITA’ STATALE DI MILANO

V. PRIMARIO DIV. CHIRURGIA GENERALE OSPEDALE V. BUZZI – MILANO

ANALYSIS OF THE USE ROUTINE SUPPORT HOSIERY

IN THE THROMBUS EMBOLIC PROPHYLAXIS

MILANO – Corso Colombo, 1 – tel. (02) 8358739

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ANALYSIS

OF THE USE ROUTINE SUPPORT HOSIERY

IN THE THROMBUS EMBOLIC

PROPHYLAXIS

INTRODUCTION

The reported incidence of venous thrombosis is increasing in unexpected

and troubling way. This is due in part to the improved and more refined

system of diagnosis (Doppler speed-meter, phlebography, Scientigraphy by

Marked Fibrin), but also to the more frequent cases of venous thrombosis as

a perioperational complication.

In the U.S.A, almost 90,000 deaths every year are caused by

thrombusembolism of the lungs after surgical operations; 21.000 cases per

year are registered in the U.K.

According to some reports, the development of venous thrombosis after

surgery occurs in 30% to 60% of people over 40 years of age, depending on

the type and duration of the surgical procedure.

In 50% cases, venous thrombosis is asympthomatic. In the same percentage

appears up during the intervention, with 40% of cases occurring immediately

after surgery. In 95% of case gets to the pulmonary embolism or the post-

phlebitic syndrome.

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EPIDEMIOLOGY

Clinical researches and anatomic pathological investigations carried out

during the last ten years have identified two main categories at risk:

• The first category is at generic risk and includes all those patients

who underwent abdominal, gynaecological, or orthopaedic operations;

• The second category is at high risk, and includes all those patients

over 40 years who had a positive history for venous thrombosis or

embolism, myocardic infarct, serious heart deseases, neoplasia, obesity,

use of oral contraceptives, lower limb fractures, varices.

The foregoing should convince all medical operators to adopt an

homogeneous prophylactic attitude and to use during the post-operational

course all possible instrumental researches in order to identify the problem

at an early stage, when and appropriate medical therapy can still be applied.

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PROPHYLAXIS

The prophylactic measures that can prevent the venous thrombosis can be

divided into two main groups:

a) Mechanical measures apt to avoid the venous stasis in the lower limbs;

b) Use of drugs that help to maintain the normal blood fluidity.

Since it is not our aim to examine the pharmacologic aspect, we shall analyse

only the problem regarding the removal of the venous stasis.

We already spoke of the high percentage of venous thrombosis arising

during surgery or in the immediate post-operational stage. We know that

the horizontal decubitus on the operating table during surgery, in total

relaxation, leads to an important decrease of the venous reflux speed with

accumulation of blood in the lower limbs, still worsened by the flexion of the

legs on the thighs and of the thighs on the pelvis.

This stasis can be emphasized by any stretching and compression

manoeuvres on the blood vessels, or in case of hypotension during surgery.

The physical prophylactic means to be used are:

1. Use of support stockings;

2. Early mobility of the patient;

3. Muscolar active exercises of the legs.

Other methods, such as the electric stimulation of the leg muscles during

surgery, the ryhmical foot compression using a pneumatic ankle-boot, or the

back flexion of the foot during surgery using mechanical pedals, have been

used and then discontinued for logistic reasons.

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Active muscular exercises and early mobility of any post-operational patient

are common practise anywhere.

On the contrary, the use of the elastic compression therapy still meet with

quite a different an attitude. As a matter of fact this therapy still usually

confined to particular cases, and practised through the use of bandages.

On the basis of what previously said, and emphasising the high number of

asymptomatic thrombus-embolism, it is hard to understand why this

prophilaxis is not standard practice when it should be advisable to make it of

compulsory use, taking into consideration the cost to advantages ratio,

favourable at length to the last ones.

There are no substantial physiological or hermodynamical differences with

regard to the use of the support methodology in respect to the other one; in

favour of the support stocking is the easier use.

The bandage has always to be applied by a doctor that must ensure the

correct graduated compression, while the stocking can be applied directly by

the patient, helped just in case by the hospital attendants.

The contra-indications to the use of the support therapy might be either

general or local. To the first group belong the oedema or pre-oedema of the

lungs caused by cardio-congenital insufficiency and arteriosclerosis with

serious peripherical ischemic risk; to the local ones belong the lower limbs

dermatitis, the wet or dry suppurative courses, the dermo-epidermic graft

recently made, the deformity of the lower limbs and the massive oedema.

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CHOICE OF THE MATERIAL

Therefore, independently from the above mentioned pathologies, each single

patient, a candidate for an chirurgical operation, should submit oneself to

prophylaxis requested by each single case.

Today there are various companies producing support hosiery that meet the

clinical requirements of Siegel (pioneer of the thrombus embolic prophylaxis

studies). He has mentioned the requirements n his numerous thesis:

a wide range of sizes and models - to be able to answer all different

anthropometrical needs, and above all, the real compressive values,

decreasing and gradual from ankle to thigh, considered efficacious if between

the values indicated on the below table:

These parameters enable, in a lying patient in narcosis, a sufficient speed of

blood pressure gradient to avoid the stasis of superficial and deep veins, and

to not create the decrease of arterial flow, as demonstrated in the following

works of Siegel, Kakkar and Arnoldi.

The producers naturally has adapted the construction methods of the

compression hosiery in way to obtain the compression values as mentioned

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above to guarantee the efficacy of the products. Also, the application of the

right size and model for every patient.

The producer can obtain with the proper compression hosiery the optimal

result only by offering a wide range of sizes and models to satisfy the

numerous anthropometrical variants of lower limbs, and by producing

models that answer in every segment to the Laplace law, where the

exercised pressure on a cylinder radius ( R) is equal to the tension (T) of the

texture, divided with R, that means that the pressure that the compression

hosiery has to exercise, is in function of the proper limb where the hosiery is

applied on.

Regarding the length of the product to be used, there are different vision

discrepancies of different authors, some like Porteous sustain that the

stocking and knee-high have the same efficacy, and some others sustain that

the femoral flow is accelerated if used the pantyhose.

The last, but not less important parameter to be considered is the resistance

to washing. Thomas has analysed, in a recent work on efficacy of

compression hosiery, an elevate number of available products in UK, after

being washed 10 times, and obtained more than discreet results.

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ANALYSIS OF A NEW PRODUCT

We have been commissioned by IBICI S.p.A to make a preliminary study of

“anti-embolus” hosiery of recent production.

The study includes:

- one regular length knee sock and one long knee sock

- one regular stocking and one long stocking

- one regular pantyhose and one long pantyhose

Each of these 6 models have been produced in three sizes: Small, Medium

and Large.

The following table shows how to choose correctly the right garment size.

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The pressure values of each product have been analysed in live with

pressure-meter type Borgnis, and the results are corresponding with those

required by the study of Siegel, as reported on the table on page 6.

We’ve noted oscillations between different models:

- between 16,1 and 18,5 mmHg on ankle

- 12 and 13,5 mmHg on calf

- 8,5 and 9 mmHg on knee

- 10 and 10,5 mmHg on 3rd superior.

Based on this experimental data and on the notions on the global literature

since 1952 until today, we’ve started to use the IBICI anti-embolus hosiery

by posing again a wider clinical study in the nearest future, by committing

on all patients of abdominal surgery the compression hosiery associated to

the calciparine prophylaxis on the risk patients, as well as by controlling in

serial way the immediate post-operation until the 4th day after operation

with Doppler sonography the veins of lower limbs.

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